Asymptomatic ACS; thoughts?

[OVeractiveBrain]

I am currently volunteering at a free clinic in San Francisco and came across an interesting case.

A 44yo African American Male with no Hx came in to examine lab values and have a 12-lead following a routine checkup. On the previous checkup a physician noticed bradycardia with irregular beats. He began to be seen at this clinic after a car vs bicycle MVA for which he was seen and released at an ED with follow up care here. Today, on his twelve lead, I (being the only ACLS certified provider besides our medical director who is "certified") noticed there was ST segment elevation in V3-V6, 3-4 mm in each lead, with reciprocal changes in II and III, no Qs (sorry, we dont have a scanner here to post the 12lead). His vitals at rest were 58 regular, 128/85, 12 clear, PEARL (assessment is limited since im technically supposed to be operating only as a medical assisstant and NOT as a paramedic). There looks like what COULD be bunny ears in III in one of the 3 serial 12 leads i did, though there is no indication of a BBB in V1 (no wide QRS, no sR / QR waves, etc). The p wave is biphasic in V1, and all QRSs are narrow. He is completely asymptomatic.

My conclusion was that it must be a preexisting bundle branch, probably physicologic from previous conditions. However, if I were a paramedic and was called for ANY complaint, I feel as though i would work this guy up as a cardiac patient (ASA definitely, Nitro x 1 BP permiting probably, morphine probably not). Given that he was coming in for a cardiac checkup (hardly anyone gets a 12lead) and it was abnormal (though the 12 year old machine read "normal sinus rhythm) I thought he should have been sent to the hospital immediately. The MD disagreed, and thought that he could go for a cardiac consult.

So I understand why she made the decision she did. It may or may not be ACS and since hes asymptomatic its probably not acute. However, I was just looking for some input as to what people would have done or what their thoughts are for this case. I mean, she didnt even order additional 12-leads (besides the three I did, back to back by about 2 minutes).

[Just Plain Ruff]

HOLY CRAPOLA BATMAN!!! Am I the only one who sees something wrong with this picture?

Can anyone say Silent MI? I can. Wow hope you documented good on this one.

what did the cardiac consult turn up?

did your Brain Surgeon do any labs? If not I'd doubly get your documentation in order. (hint hint - suspect a visit from your local process server at your door sometime in the future if this guy had any negative effects of waiting for a cardiac consult.)

I hope the guy did good.

You are right to be concerned. You said it right - if you had seen him in the ambulance you would have worked him up for MI and transported to the hospital.

I think your doc did a badddddddddddd thing.

[emt322632]

I would have worked them up for ACS as well...you said he had no history, therefore I would assume that the ST changes aren't from old ischemia or an old infarct. Were there cardiac enzymes drawn? No pain, dyspnea, or n&v at all?

I had a woman a few weeks ago who presented with N&V, ST elevation in lead 2, no 12 lead done (shame on me). She didn't have ACS though, just a viral infection...ST elevation was totally unrelated. So maybe it's nothing, but I would think your doc would have at least done a workup just to make sure.

[OVeractiveBrain]

Keep in mind every body that this is coming from a primary care center. They dont have a hospital backing behind them, nor the resources that we are used to hearing about. Not trying to sway one way or another, just an info bit

[ERDoc]

Keep in mind every body that this is coming from a primary care center. They dont have a hospital backing behind them, nor the resources that we are used to hearing about. Not trying to sway one way or another, just an info bit

You're right young padawan, they don't have the resources, so the pt should have been sent to the ER where the resources are available. We have a middle aged AA male. Right there increases the risk for ACS and silent MIs. Based on the history, I doubt this pt has no hx, but just hasn't been diagnosed yet. He probably has not seen a doctor in years if he is getting his follow up from a free clinic. For all we know, his cholesterol is 1000 and he's got a 90% stenosis of his LAD. We have a recent EKG for comparison and see ST elevations in continuous leads. This yells ACS/STEMI until proven otherwise. He needs an ER, enzymes and stress/cath.

[Just Plain Ruff]

ok, I'm gonna piss some people off here but so be it

could this patient not have been treated as agressively as they should have because he was being treated at a free clinic?? Not saying that free clinics are bad because they serve a significant and important purpose but since he was at the "FREE" clinic and more than likely in a lower income bracket with no insurance that he was treated less than someone who would have had insurance and at a PAY clinic?

sorry for ruffling any feathers but don't ya think this might have been somewhat to blame?

[ERDoc]

ok, I'm gonna piss some people off here but so be it

could this patient not have been treated as agressively as they should have because he was being treated at a free clinic?? Not saying that free clinics are bad because they serve a significant and important purpose but since he was at the "FREE" clinic and more than likely in a lower income bracket with no insurance that he was treated less than someone who would have had insurance and at a PAY clinic?

sorry for ruffling any feathers but don't ya think this might have been somewhat to blame?

I don't think that is the issue here (not to say that it doesn't happen). It wasn't like sending the pt to the ER was going to affect the clinic any, if anything it shifted the burdeon of doing a workup off of the clinic. I think this case was mismanaged from what we have been told.